To protect patients, Congress must pass comprehensive PBM reform

No one should have to struggle to access the prescription treatments they need to live a healthier, happier and more productive life. Yet all too often, health insurers and their pharmacy benefit managers (PBMs) can get in the way of patients and the care they need by using profit-driven policies to stifle patient access and force out-of-pocket expenses ever higher.

As a patient living with multiple sclerosis, I have been on the receiving end of unfair PBM practices more times than I would like to count. Finding effective treatment options for MS can be difficult enough, as they don’t always work the same from patient to patient. PBM policies that restrict or deny access to doctor-prescribed care make things that much more challenging for patients with MS and a range of other debilitating diseases and illnesses.

That is why I believe Congress must intervene and pass meaningful PBM reform before the end of this legislative session. As a patient, it was disappointing to watch lawmakers fail to prioritize PBM reform last year, particularly when members of both political parties spoke out about the pressing need for it. Lawmakers in Congress cannot make the same mistake this year; patients in Nevada and across the country deserve a solution sooner rather than later.

It is heartening to see that Sen. Jacky Rosen, D-Nev., is stepping up to address some of the problems PBMs create for patients.New legislation she has introduced along with Sen. John Cornyn, R-Texas, would help lower prescription drug costs and out-of-pocket expenses for seniors on Medicare by ensuring their coinsurance payments are based on the actual prices PBMs pay drug manufacturers for these medications — not the pre-negotiation list prices. Currently, PBMs calculate the costs seniors pay for their medications based on their list price, which is almost always higher than what insurers and PBMs end up paying.

While this legislation could help Medicare beneficiaries in Nevada and across the country, there is still much more work to do to protect all patients from the manipulative, self-serving business practices and policies PBMs use to maximize their profits at the expense of patient access.

PBMs’ arcane policies help them cut costs and boost profits by creating new access barriers for patients. These policies can lead to lengthy delays, which can be detrimental to patients’ well-being. Not only do these self-serving policies undermine patient access, but, as in the case of patient steering, they can also threaten the future of local independent pharmacies.

In addition to these access-restricting policies, PBMs also use their role as health care middlemen to negotiate with drug manufacturers and secure significant rebates on certain prescription medications. However, instead of passing those rebates down to patients at the pharmacy to help them reduce their out-of-pocket costs, PBMs will absorb these savings to inflate their already massive profit margins. This, on top of the fact that PBM fees are linked to the list price of medications, forces vulnerable patients to pay higher costs and more out of their pocket simply so PBMs can stay as profitable as possible.

While Rosen’s effort to tackle PBM abuse for Medicare beneficiaries is a start, lawmakers need to think bigger when it comes to protecting all patients from these harmful practices. Passing the Delinking Revenue from Unfair Gouging (DRUG) Act would be a tremendous step forward in reforming PBM policies that threaten patient access.

With little time left on the legislative calendar, Congress must act quickly to pass the DRUG Act and help increase transparency into PBMs and their abusive practices. Too many patients cannot afford for their lawmakers to kick the can down the road on this issue any longer. The time for real, meaningful PBM reform that puts patients over profits is now.

Michelle O’Bannon is a native Nevadan and lives and owns a business in Las Vegas.